Supporting Struggling Trainees with Performance Issues: Lessons from a UK Model

Approximately 6-9% of trainees will have performance issues of variable degrees with 3-5% of trainees struggling to complete their training and requiring additional targeted time or an extension of training. Some even leave the profession. The environment is complex, often chaotic and overstretched, and, now, made more difficult due to the impact of COVID-19 on medical training. Addressing learning and implementing new behaviours is a challenge and important, as there are still 'never events', and medical errors sadly can include wilful neglect and assault. Such traumatic experiences can be a huge drain of resources for faculty, who often feel underprepared to deal with such occurrences. Failure to address them can lead to bitterness and loss of the medical workforce, rarely suicide, huge remedial costs, and legal challenges to educational institutions and employers. The purpose of this paper is to gain an understanding of why trainees struggle and/or fail and to be able to analyse the causes of poor performance; to know how to pick up these issues early and raise them; and to ultimately deal effectively with performance problems to get a good outcome for the trainees, patients, and institutions.

Empowering trainees through understanding learning theory and changes in medical education

Background: Empowering trainees to think critically about decision making should result in the National Health Service (NHS) being more efficient and cost effective, thereby reducing the wastage of precious NHS resources on unnecessary investigations, treatment, and consequently putting patients at risk. There is a major shift from acquiring knowledge to critical analysis and synthesis of information for decision making. Trainees must understand how healthcare systems function and consequences of their decisions on budgets and patient care. Equally, faculty need to appreciate that their role is changing from information provider to facilitator of learning through feedback and supervision, role modelling, and innovator of learning approaches.

Methods: A survey of 100 postgraduate trainees from the Severn Deanery was conducted on SurveyMonkey in March 2020 and January 2021.  The survey consisted of eight questions focusing on trainee responses to participation in clinical decision-making in the inpatient setting. An additional question on communication with the patient was included in the second iteration.

Results: With a response rate of 80, only 35% of trainees had their findings regularly verified by the consultant. One third of trainees reported that decisions were made by the consultant without asking their opinion on investigations or management. It was unusual for trainees to have any interaction with patients on consultant ward rounds and to understand the rationale for the requested investigations.

Conclusion: The poor consultant trainee interaction represents a serious lost opportunity for experiential learning with real time feedback. Training programmes should support trainees being given opportunities to nurture analytical, problem-solving skills, dealing with uncertainty among other attributes of patient management. Trainees need to become competent through the art of critical thinking and develop a professional identity. Through this they develop confidence and competence leading to better patient outcomes, and prevention of the depletion of healthcare budgets.

Facial discoid dermatosis: A cosmetically disfiguring and challenging condition to treat

Facial discoid dermatosis (FDD) is a recently described condition comprising discrete facial papulo‐squamous lesions. We report three cases that clinically and histologically resemble FDD and demonstrate its resistance to treatment. Awareness of this new clinical entity will allow early diagnosis and the ability to make patients aware that there is unlikely to be a successful treatment. However, our study suggests that although FDD can persist for many years, it appears to remain stable.

How can medical schools create the general practice workforce? An international perspective

This article was migrated. The article was marked as recommended. Medical schools are responsible for producing the future medical workforce that is fit for purpose to meet the needs of patients. The burden of care largely falls upon primary care, a specialty which has been under-doctored, under-resourced, culturally not valued, and whose status has been subordinate to secondary care. In addition, the demographic changes of increasing longevity and chronic diseases, have increased the demand for healthcare at a time when governments' finances are stretched more than ever. The poor state of recruitment to the primary care workforce is a global phenomenon as evidenced by similar issues in North America, UK and the Middle East including Turkey. This contradicts the fact that the strength of primary care has a direct effect on the health of the nation. This paper presents an international perspective of why primary care is important, the reasons why new graduates shy away from a career in primary care, and what steps medical schools, residency programmes and governments should undertake to encourage medical students to make primary care a preferred career choice.

Accelerated transsulfuration metabolically defines a discrete subclass of amyotrophic lateral sclerosis patients

Amyotrophic lateral sclerosis is a disease characterized by progressive paralysis and death. Most ALS-cases are sporadic (sALS) and patient heterogeneity poses challenges for effective therapies. Applying metabolite profiling on 77-sALS patient-derived-fibroblasts and 43-controls, we found ~25% of sALS cases (termed sALS-1) are characterized by transsulfuration pathway upregulation, where methionine-derived-homocysteine is channeled into cysteine for glutathione synthesis. sALS-1 fibroblasts selectively exhibited a growth defect under oxidative conditions, fully-rescued by N-acetylcysteine (NAC). [U–¹³C]-glucose tracing showed transsulfuration pathway activation with accelerated glucose flux into the Krebs cycle. We established a four-metabolite support vector machine model predicting sALS-1 metabotype with 97.5% accuracy. Both sALS-1 metabotype and growth phenotype were validated in an independent cohort of sALS cases. Importantly, plasma metabolite profiling identified a system-wide cysteine metabolism perturbation as a hallmark of sALS-1. Findings reveal that sALS patients can be stratified into distinct metabotypes with differential sensitivity to metabolic stress, providing novel insights for personalized therapy.

Healthcare educational leadership in the twenty-first century

Education leadership has to intimately lead our future champions of students and nurture them as professional, dynamic, reflective scholars to deal with the complex world of healthcare in a post-truth era. In addition the organization structure needs to develop faculty from clinical and educational supervisors through to program directors and Deans. Leadership theories have taken over from the previous decades of teaching on management. The current dogma is intransigent, and produces silos such as leadership and followership or leaders and managers as class differences which reinforces the obdurate and narrow-minded approach. This contradicts the open society of creating change agents, critical thinkers, and scholars of the conceptual age of post modernity who in a knowledge based economy need to take our world forward. Additionally healthcare is rapidly becoming unaffordable as returns on GDP investment do not give the returns that we as patients and tax payers need. There is the obvious waste of people and funding on constant reorganizations and short-term thinking. This reflects the sort of leaders and organizations we are developing and how decisions are made. This paper through ideas confronts the myths and flaws of current leadership teaching in an education framework. It makes the case for innovative, creative, adroit, adept, experiential learners who can see the bigger picture, avoid harm and be able to cope with complexity and uncertainty, thereby creating a paradigm shift so that future leaders can problem solve, through the ongoing seismic changes that healthcare faces.

HSP90-incorporating chaperome networks as biosensor for disease-related pathways in patient-specific midbrain dopamine neurons

Environmental and genetic risk factors contribute to Parkinson’s Disease (PD) pathogenesis and the associated midbrain dopamine (mDA) neuron loss. Here, we identify early PD pathogenic events by developing methodology that utilizes recent innovations in human pluripotent stem cells (hPSC) and chemical sensors of HSP90-incorporating chaperome networks. We show that events triggered by PD-related genetic or toxic stimuli alter the neuronal proteome, thereby altering the stress-specific chaperome networks, which produce changes detected by chemical sensors. Through this method we identify STAT3 and NF-κB signaling activation as examples of genetic stress, and phospho-tyrosine hydroxylase (TH) activation as an example of toxic stress-induced pathways in PD neurons. Importantly, pharmacological inhibition of the stress chaperome network reversed abnormal phospho-STAT3 signaling and phospho-TH-related dopamine levels and rescued PD neuron viability. The use of chemical sensors of chaperome networks on hPSC-derived lineages may present a general strategy to identify molecular events associated with neurodegenerative diseases.

The early molecular events that ultimately lead to neuronal cell death in pathologies such as Parkinson’s disease are poorly understood. Here the authors use pluripotent stem-cell-derived human midbrain neurons and chemical biology tools to gain molecular level insight into the events induced by toxic and genetic stresses that mimic those occurring during neurodegeneration.

RNA polymerase V targets transcriptional silencing components to promoters of protein-coding genes

Transcriptional gene silencing controls transposons and other repetitive elements through RNA-directed DNA methylation (RdDM) and heterochromatin formation. A key component of the Arabidopsis RdDM pathway is ARGONAUTE4 (AGO4), which associates with siRNAs to mediate DNA methylation. Here, we show that AGO4 preferentially targets transposable elements embedded within promoters of protein-coding genes. This pattern of AGO4 binding cannot be simply explained by the sequences of AGO4-bound siRNAs; instead, AGO4 binding to specific gene promoters is also mediated by long non-coding RNAs (lncRNAs) produced by RNA polymerase V. lncRNA-mediated AGO4 binding to gene promoters directs asymmetric DNA methylation to these genomic regions and is involved in regulating the expression of targeted genes. Finally, AGO4 binding overlaps sites of DNA methylation affected by the biotic stress response. Based on these findings, we propose that the targets of AGO4-directed RdDM are regulatory units responsible for controlling gene expression under specific environmental conditions.

The future training of surgeons to manage patients with cleft lip and palate disorders

The development of the face and the upper lip occurs during the fifth to ninth week of pregnancy. A cleft is a separation or split in either the upper lip or palate and sometimes both. Cleft lip and palate can occur on its own (nonsyndromic) or is sometimes part of a wider series of birth defects (syndromic).

Molecular mapping of 36 soybean male-sterile, female-sterile mutants

Mutability of the w(4) flower color locus in soybean [Glycine max (L.) Merr.] is conditioned by an unstable allele designated w(4)-m. Germinal revertants, purple-flower plants, recovered among self-pollinated progeny of mutable flower plants were associated with the generation of necrotic root, chlorophyll-deficiency, and sterility mutations. Thirty-seven male-sterile, female-sterile mutant lines were generated from 37 independent reversion events at the w(4)-m locus. The first germinal revertant study had one male-sterile, female-sterile mutant (st8, T352), located on Molecular Linkage Group (MLG) J. The second study had 36 germinal-revertant derived sterility mutants descended from four mutable categories of w(4)-m. The mutable categories were designated; (1) low frequency of early excisions, (2) low frequency of late excisions, (3) high frequency of early excisions, and (4) high frequency of late excisions. The objectives of the present study were to; (1) molecularly map the 36 male-sterile, female-sterile mutants, and to (2) compare map locations of these mutants with T352 (st8), identified from the first germinal revertant study. Thirty-three of 36 male-sterile, female-sterile mutations were derived from germinal reversions that were classified in the late excision categories. Thirty-five male-sterile mutants mapped to the st8 region on MLG J. The only exception mapped to MLG G. Most likely mutants were generated through insertion of a putative transposon that was excised from the w(4) locus. The location of 36 of 37 mutations to a single chromosomal region suggests preference for sequence-dependent insertion.

Soybean phytophthora resistance gene Rps8 maps closely to the Rps3 region

Root and stem rot is one of the major diseases of soybean. It is caused by the oomycete pathogen Phytophthora sojae. A series of resistance genes (Rps) have been providing soybean with reasonable protection against this pathogen. Among these genes, Rps8, which confers resistance to most P. sojae isolates, recently has been mapped. However, the most closely linked molecular marker was mapped at about 10 cM from Rps8. In this investigation, we attempted to develop a high-density genetic map of the Rps8 region and identify closely linked SSR markers for marker-assisted selection of this invaluable gene. Bulk segregant analysis was conducted for the identification of SSR markers that are tightly linked to Rps8. Polymorphic SSR markers selected from the Rps8 region failed to show cosegregation with Phytophthora resistance. Subsequently, bulk segregant analysis of the whole soybean genome and mapping experiments revealed that the Rps8 gene maps closely to the disease resistance gene-rich Rps3 region.

Deletion mapping of homoeologous group 6-specific wheat expressed sequence tags

To localize wheat (Triticum aestivum L.) ESTs on chromosomes, 882 homoeologous group 6-specific ESTs were identified by physically mapping 7965 singletons from 37 cDNA libraries on 146 chromosome, arm, and sub-arm aneuploid and deletion stocks. The 882 ESTs were physically mapped to 25 regions (bins) flanked by 23 deletion breakpoints. Of the 5154 restriction fragments detected by 882 ESTs, 2043 (loci) were localized to group 6 chromosomes and 806 were mapped on other chromosome groups. The number of loci mapped was greatest on chromosome 6B and least on 6D. The 264 ESTs that detected orthologous loci on all three homoeologs using one restriction enzyme were used to construct a consensus physical map. The physical distribution of ESTs was uneven on chromosomes with a tendency toward higher densities in the distal halves of chromosome arms. About 43% of the wheat group 6 ESTs identified rice homologs upon comparisons of genome sequences. Fifty-eight percent of these ESTs were present on rice chromosome 2 and the remaining were on other rice chromosomes. Even within the group 6 bins, rice chromosomal blocks identified by 1-6 wheat ESTs were homologous to up to 11 rice chromosomes. These rice-block contigs were used to resolve the order of wheat ESTs within each bin.

A 2500-locus bin map of wheat homoeologous group 5 provides insights on gene distribution and colinearity with rice

We constructed high-density deletion bin maps of wheat chromosomes 5A, 5B, and 5D, including 2338 loci mapped with 1052 EST probes and 217 previously mapped loci (total 2555 loci). This information was combined to construct a consensus chromosome bin map of group 5 including 24 bins. A relatively higher number of loci were mapped on chromosome 5B (38%) compared to 5A (34%) and 5D (28%). Differences in the levels of polymorphism among the three chromosomes were partially responsible for these differences. A higher number of duplicated loci was found on chromosome 5B (42%). Three times more loci were mapped on the long arms than on the short arms, and a significantly higher number of probes, loci, and duplicated loci were mapped on the distal halves than on the proximal halves of the chromosome arms. Good overall colinearity was observed among the three homoeologous group 5 chromosomes, except for the previously known 5AL/4AL translocation and a putative small pericentric inversion in chromosome 5A. Statistically significant colinearity was observed between low-copy-number ESTs from wheat homoeologous group 5 and rice chromosomes 12 (88 ESTs), 9 (72 ESTs), and 3 (84 ESTs).

A chromosome bin map of 16,000 expressed sequence tag loci and distribution of genes among the three genomes of polyploid wheat

Because of the huge size of the common wheat (Triticum aestivum L., 2n = 6x = 42, AABBDD) genome of 17,300 Mb, sequencing and mapping of the expressed portion is a logical first step for gene discovery. Here we report mapping of 7104 expressed sequence tag (EST) unigenes by Southern hybridization into a chromosome bin map using a set of wheat aneuploids and deletion stocks. Each EST detected a mean of 4.8 restriction fragments and 2.8 loci. More loci were mapped in the B genome (5774) than in the A (5173) or D (5146) genomes. The EST density was significantly higher for the D genome than for the A or B. In general, EST density increased relative to the physical distance from the centromere. The majority of EST-dense regions are in the distal parts of chromosomes. Most of the agronomically important genes are located in EST-dense regions. The chromosome bin map of ESTs is a unique resource for SNP analysis, comparative mapping, structural and functional analysis, and polyploid evolution, as well as providing a framework for constructing a sequence-ready, BAC-contig map of the wheat genome.

Chromosome bin map of expressed sequence tags in homoeologous group 1 of hexaploid wheat and homoeology with rice and Arabidopsis

A total of 944 expressed sequence tags (ESTs) generated 2212 EST loci mapped to homoeologous group 1 chromosomes in hexaploid wheat (Triticum aestivum L.). EST deletion maps and the consensus map of group 1 chromosomes were constructed to show EST distribution. EST loci were unevenly distributed among chromosomes 1A, 1B, and 1D with 660, 826, and 726, respectively. The number of EST loci was greater on the long arms than on the short arms for all three chromosomes. The distribution of ESTs along chromosome arms was nonrandom with EST clusters occurring in the distal regions of short arms and middle regions of long arms. Duplications of group 1 ESTs in other homoeologous groups occurred at a rate of 35.5%. Seventy-five percent of wheat chromosome 1 ESTs had significant matches with rice sequences (E < or = e(-10)), where large regions of conservation occurred between wheat consensus chromosome 1 and rice chromosome 5 and between the proximal portion of the long arm of wheat consensus chromosome 1 and rice chromosome 10. Only 9.5% of group 1 ESTs showed significant matches to Arabidopsis genome sequences. The results presented are useful for gene mapping and evolutionary and comparative genomics of grasses.

Group 3 chromosome bin maps of wheat and their relationship to rice chromosome 1

The focus of this study was to analyze the content, distribution, and comparative genome relationships of 996 chromosome bin-mapped expressed sequence tags (ESTs) accounting for 2266 restriction fragments (loci) on the homoeologous group 3 chromosomes of hexaploid wheat (Triticum aestivum L.). Of these loci, 634, 884, and 748 were mapped on chromosomes 3A, 3B, and 3D, respectively. The individual chromosome bin maps revealed bins with a high density of mapped ESTs in the distal region and bins of low density in the proximal region of the chromosome arms, with the exception of 3DS and 3DL. These distributions were more localized on the higher-resolution group 3 consensus map with intermediate regions of high-mapped-EST density on both chromosome arms. Gene ontology (GO) classification of mapped ESTs was not significantly different for homoeologous group 3 chromosomes compared to the other groups. A combined analysis of the individual bin maps using 537 of the mapped ESTs revealed rearrangements between the group 3 chromosomes. Approximately 232 (44%) of the consensus mapped ESTs matched sequences on rice chromosome 1 and revealed large- and small-scale differences in gene order. Of the group 3 mapped EST unigenes approximately 21 and 32% matched the Arabidopsis coding regions and proteins, respectively, but no chromosome-level gene order conservation was detected.

Sildenafil and Nasal Obstruction

OBJECTIVE

Sildenafil (Viagra; Pfizer), a phosphodiesterase inhibitor, promotes penile erection through increased intracellular cyclic guanine monophosphate (a second messenger) in response to nitric oxide (a first messenger) release following sexual stimulation. Nitric oxide is involved in nasal vasodilation, secretion, and mucociliary clearance. The aim of this study was to assess the effect of sildenafil on nasal patency.

DESIGN

Pilot study.

SETTING

Teaching hospital.

METHODS

Nasal patency was assessed by a visual analogue score and by measurement of the peak nasal inspiratory flow (PNIF) in five subjects before and after administration of sildenafil.

MAIN OUTCOME MEASURES

Visual analogue score and PNIF.

RESULTS

There was a significant increase in the subjective sensation of nasal obstruction (p = .003; -9.6 +/- 2.7, -15.4 to -3.7 [mean +/- SEM, 95% CI) and a significant reduction of PNIF (p < .001; 70.7 +/- 13.2, 43.1 to 98.3).

CONCLUSIONS

This pilot study suggests that nasal patency may be reduced following the administration of sildenafil. The role of phosphodiesterase inhibitors in nasal physiology merits further investigation.

Candidate-gene cloning and targeted marker enrichment of wheat chromosomal regions using RNA fingerprinting-differential display

The usefulness of the RNA fingerprinting-differential display technique in gene cloning and targeted marker enrichment in wheat is demonstrated. A small region of chromosome 5BL was targeted that contains Ph1, a chromosome-pairing regulator gene. The cultivar Chinese Spring (CS) and mutant ph1b are almost identical except for chromosome 5BL, which, in the mutant line, carries an interstitial deletion encompassing the Ph1 gene. Poly(A)+ RNA of the two lines from anthers at developmental stages ranging from pre-meiotic mitosis to anaphase II was PCR-amplified using 38 pairwise combinations of 19 primers. The 35S-labeled amplified products were size-separated on denaturing polyacrylamide-urea gels. A total of 3154 fragment bands were observed, of which 43 were present in CS but absent in the ph1b mutant. These 43 fragment bands were eluted, re-amplified, and used as probes in gel-blot DNA analyses of wheat group 5 nullisomic-tetrasomic lines and the ph1b mutant. Twenty-four of these 43 probes were single- or few-copy sequences. Eight of the 24 probes mapped to wheat group 5 and five mapped to the deletion of the ph1b mutant. Three of these five probes were further localized to the submicroscopic region containing the Ph1 gene, by using two deletion lines flanking the region. Northern-blot analysis revealed that the gene corresponding to one of these three probes expresses mainly during meiosis and is from the B genome.

Identification and physical localization of useful genes and markers to a major gene-rich region on wheat group 1S chromosomes

The short arm of Triticeae homeologous group 1 chromosomes is known to contain many agronomically important genes. The objectives of this study were to physically localize gene-containing regions of the group 1 short arm, enrich these regions with markers, and study the distribution of genes and recombination. We focused on the major gene-rich region ("1S0.8 region") and identified 75 useful genes along with 93 RFLP markers by comparing 35 different maps of Poaceae species. The RFLP markers were tested by gel blot DNA analysis of wheat group 1 nullisomic-tetrasomic lines, ditelosomic lines, and four single-break deletion lines for chromosome arm 1BS. Seventy-three of the 93 markers mapped to group 1 and detected 91 loci on chromosome 1B. Fifty-one of these markers mapped to two major gene-rich regions physically encompassing 14% of the short arm. Forty-one marker loci mapped to the 1S0.8 region and 10 to 1S0.5 region. Two cDNA markers mapped in the centromeric region and the remaining 24 loci were on the long arm. About 82% of short arm recombination was observed in the 1S0.8 region and 17% in the 1S0.5 region. Less than 1% recombination was observed for the remaining 85% of the physical arm length.

Inhibition of isolated rat and human detrusor muscle contraction by disopyramide

1. The aim of this study was to investigate the effect of in vitro and in vivo disopyramide treatment on human and rat isolated detrusor muscle contractile response. Muscle strips were suspended in an organ bath chamber containing Kreb's solution at 37 degrees C aerated with 95% oxygen and 5% carbon dioxide. 2. Disopyramide antagonized significantly the contractile response of isolated human detrusor muscle to carbachol stimulation, shifting the concentration-response curve to the right in a parallel manner. The pA2 for competitive inhibition was estimated to be 6.4 with a slope of 0.64 for disopyramide. 3. Rat detrusor muscle contractile response to electrical field stimulation (EFS) was inhibited by 28% (P < 0.01) after in vitro administration of disopyramide (7.5 x 10(-6) M). Disopyramide had no effect on the atropine-resistant component of the response to EFS or on spontaneous contractions of isolated rat detrusor muscle strips. The concentration-response curve to carbachol was competitively antagonized by disopyramide with a pA2 of 6.3 and a Schild curve a slope of 0.85. 4. Disopyramide (7.5 x 10(-6) M) had no effect on rat detrusor contractile response to low concentrations of KCl but at high concentrations contraction was reduced significantly by 16% (P < 0.01). 5. In vivo treatment of rats with disopyramide for 8 days or with a single dose had a significant inhibitory effect on the contractile response of detrusor muscle strips. 6. In conclusion, disopyramide had a significant anticholinergic effect on isolated human and rat detrusor muscle contraction.

A double blind, placebo controlled study of intracavernosal vasoactive intestinal polypeptide and phenotolamine mesylate in a novel auto-injector for the treatment of non-psychogenic erectile dysfunction

Three hundred and four patients with non-psychogenic erectile dysfunction (ED) completed a dose assessment phase with intracavernosal injection utilizing 25 micrograms vasoactive intestinal polypeptide (VIP) combined with phentolamine mesylate 1.0 mg (VIP/P-1) or 2.0 mg (VIP/P-2) in an auto-injector for a response rate of 83.9%. In a sub-group of 183 patients who withdrew from one or more previous ED therapies, 82% responded with an erection suitable for intercourse. One hundred and ninety-five patients were subsequently treated in a placebo controlled phase. 75.1% responded to VIP/P-1, 12% to placebo (P < 0.001); 66.5% responded to VIP/P-2, 10.3% to placebo (P < 0.001), with the median duration of erection of 54 min. The principal adverse event was transient facial flushing in 2770 injections (33.9%). There was no pain post injection and two episodes of priapism (0.05%). Only nine patients withdrew because of adverse events. Over 85% and 95% of patients were satisfied with the drug and auto-injector, respectively. Over 81% of patients and 76% of partners reported an improved quality of life.

Inflammatory pseudotumour of the urinary bladder

An inflammatory pseudotumour that arose in the urinary bladder of a 33-year-old woman is reported. This is the twelfth reported example of this unusual non-neoplastic lesion that may be mistaken for a sarcoma. The lesion was composed predominantly of spindle cells that by routine light microscopical, ultrastructural and immunohistochemical examination had features consistent with myofibroblasts. Awareness of this unusual lesion is important to prevent its misinterpretation.

Multicentre controlled trial of indoramin in the symptomatic relief of benign prostatic hypertrophy

A group of 139 patients with symptoms of bladder outflow obstruction due to benign prostatic hypertrophy were entered into a double-blind, parallel group, multicentre study of 2 doses of indoramin versus placebo. There were 18 withdrawals or exclusions, leaving 121 patients for analysis. After 8 weeks, mean peak flow rates increased more in patients treated with indoramin 20 mg bd than in those with placebo. The difference between indoramin 20 mg nocte and placebo was not significant. The change in mean peak flow rate for the higher dose of indoramin represented an increase of 50%. Both patients and investigators reported that the patients' symptoms had improved significantly on both indoramin 20 mg bd and 20 mg nocte; 9 patients were withdrawn because of adverse events, 5 taking placebo and 2 in each of the treatment groups. It was concluded that indoramin 20 mg bd was both effective and well tolerated in the management of symptomatic benign prostatic hypertrophy.

A randomised comparison of two postoperative fluid regimens

Postoperative paralytic ileus follows all significant gastrointestinal surgery. Its duration is variable and has led to a variety of empirical and time-consuming oral fluid regimens. We have compared a traditional method of fluid administration with an unstructured, simpler, patient-determined approach. A series of 102 patients on a general surgical ward who required intravenous fluids on the day after surgery were randomised by a closed envelope system to one of two protocols and followed prospectively. Of these, 12 patients were erroneously randomised or unable to fulfil trial requirements. The first, 'regulated' group (n = 41) received hourly aliquots of oral fluid as determined by twice daily ward rounds according to ward routine. The second, 'unregulated' group (n = 49) were given a jug of water and instructed to drink as desired. Patients in the regulated group received less of their postoperative fluids by the oral route at all stages of recovery but there were no significant differences in the mean durations of intravenous therapy, nasogastric intubation or hospital stay. Postoperative complication and mortality rates were also similar. Patients who underwent gastric or duodenal procedures (n = 14) showed a similar pattern of results. We conclude that 'patient-determined' regulation of postoperative oral fluid intake is safe and effective and may greatly simplify ward management.